I’m standing outside the 11th floor elevators of Bellevue Hospital clutching my stethoscope. My breaths are shallow, my palms are sweaty, and my heart is pounding in my chest. I see a resident walking towards me. Her lips are moving, but the words do not register. She asks me for a second time: “are you okay?” We had just finished a rapid together, and I think about how to respond.
I remember arriving at the hospital that Sunday morning expecting a slower day. My resident and I have plans to practice ultrasound, review acid-base disorders, and write-up an admission. By 10:00am, the day is anything but calm. We hear over the intercom: “rapid response team.” We rush to the scene for the day’s first rapid. Plenty of house staff have already arrived. I have grown accustomed to my role in rapids: I grab a bucket with ice, search for supplies, and wait for med consult’s directions. After 30 minutes, the patient is stable.
Behind on our day, my resident and I take the elevator down to the emergency room to meet our new admission. Just as we arrive, we hear “rapid response team.” We rush to the designated room, but here, the air feels heavier. This rapid is different. The patient is barely hanging onto life; she is cold, unarousable, and struggles with her final breath.
“No pulse!” a resident calls out. We are short on hands, so I am immediately put to work, no time for my usual supply grab. One resident starts chest compressions, another coordinates the ECG, and the attending searches for an automated CPR machine. I am asked to hold onto epinephrine syringes, tracking the amount administered and the time between each bolus. I can do this. This is why I went to medical school: to be helpful, to be useful. A few minutes later, more house staff arrives, and the room erupts into an orchestra at the direction of med consult. Someone is printing labels, someone drawing blood, someone is working the automated CPR machine. Just as anesthesiology finishes intubation, someone yells: “we have a pulse!” The team stops chest compressions, and I breathe a sigh of relief. The rapid is far from over, but it feels like we are going to bring this patient back to life. I hear over the intercom:
“rapid response team.”
Everyone’s eyes dart to med consult, wondering how we will handle two rapids at once. My resident, who will soon be a fellow in critical care, offers to lead half the house staff to the second rapid. As he leaves, an attending enters the room: “the patient’s family wants resuscitation by all means necessary.”
Five minutes later, the patient once again has no pulse. A resident starts chest compressions and I am directed to help with the automated CPR machine. My instructions are clear: hold the machine steady, pause it at the direction of med consult, and check for pulses. I hold on tight. The machine shoves with enough power to push the patient’s chest into her back. I take deep breaths to steady myself. We’ve gotten the pulse back before. We can get it back again.
Two minutes pass. “Pulse check!”, med consult yells. I stop the machine and place two fingers on the patient’s carotid. I make eye contact with the attending who is checking the femoral pulse to ensure we are in agreement. “No pulse,” I say firmly. I cannot stop my legs from shaking, but I refuse to let my voice waver. The cycle continues for minutes that seem like days, and slowly I sense the patient slipping away. The attending leaves to see if the family wants us to attempt open heart massage. This is where the family draws the line. My fingers clench ever so tightly across the CPR machine, as if doing so can change the trajectory of fate. Med consult informs us that we will do one final pulse check. The room falls silent; the only thing I hear is the steady oscillation of the CPR machine working to keep our patient alive. I am asked to turn off the machine.
As I go to flip the switch, it dawns on me: this is likely the last time blood will ever circulate through her body. I have never met this person before, and yet, I am entrusted with turning on and off the only device which continues to perfuse her organs. For one final time, I place two fingers on her carotid, waiting, willing for something to bounce against my fingers. Words become trapped as my voice finally betrays me. An attending moves to the bedside to check the carotid.
“Time of death, 12:03pm.” We bow our heads for a moment of silence.
As I walk out of the room, I realize that I had just seen my first death. All I can think to myself is did we do something wrong? Could we have done something differently? Part of me knows that we did everything right, but as medical students, we are taught to look for error, to learn from our mistakes. I pass the patient’s granddaughter, and I am reminded of the patient’s wishes. I am reminded that part of our job is to help patients die. For our patient, she did not want to leave this world without a fight. Every life saving measure the patient wanted, we provided.
I’m standing outside the 11th floor elevators of Bellevue Hospital clutching my stethoscope. For the second time, a resident asks me “are you okay?” I think of what to say. “No,” I tell her, “but I will be.” I ride the elevator down to the emergency room to meet my resident for our new admission. He takes a moment to pat me on the back. I take a deep breath, put a big smile on my face, and pull back the ED curtain: “so, Mr. Smith, what brings you into the hospital today?”